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PROGRAMS & MEDICATIONS BY DISEASE
STATE/CONDITION |
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BLOOD THINNERS |
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How to use MAGIC (document is
interactive, clickable)
1. Find
desired medication via alphabetical directory or medications by disease
state/condition
a. TIP:
Use CTRL + F to quickly search for medication
2. You
will be directed to the manufacturer program eligibility criteria for the
selected medication
|
Income documentation required |
Medication delivery |
FPL cutoff (%) or income
threshold for single person($) |
FPL cutoff 2 |
FPL cutoff 3 |
|
|
AADI |
No |
Office |
400 |
|
|
|
AbbVie |
No |
Home |
$81,150 |
|
|
|
Acadia |
Application through office staff |
Home |
Any for uninsured |
|
|
|
ADC |
No |
Home |
550 |
|
|
|
Amgen |
No |
Home |
500 |
|
|
|
AstraZeneca |
No |
Home |
300 |
500 |
|
|
Boehringer Ingelheim |
No |
Home |
250 |
|
|
|
Bristol Myers Squibb |
No-but encouraged |
Home |
300 |
|
|
|
GlaxoSmithKline (GSK) |
No |
Home |
250 |
|
|
|
Johnson & Johnson |
No |
Home |
300 |
400 |
600 |
|
Lilly |
No |
Home |
300 |
400 |
500 |
|
Merck |
No |
Home |
400 |
|
|
|
MyPraluent |
No-but encouraged |
Home |
300 |
|
|
|
Mylan (Viatris) |
Yes |
Home |
400 |
500 |
|
|
Nestle Health |
Yes |
Home |
400 |
|
|
|
Novartis |
No |
Home |
$70,000 |
|
|
|
Novo Nordisk |
No |
Office |
400 |
|
|
|
Otsuka |
Yes |
Home |
300 |
700 |
|
|
Pfizer |
Yes |
Office |
$49,960 |
400 |
|
|
Pfizer Oncology |
No |
Home |
500 |
|
|
|
Radius |
No-SSN acceptable |
Home |
300 |
|
|
|
Roche (Genentech) |
No |
Home |
$75,000 |
|
|
|
Sanofi |
No |
Office |
400 |
|
|
|
Sunovion |
Yes |
Home |
300 |
|
|
|
TAKEDA |
Yes |
Home |
500 |
|
|
|
TEVA |
No |
Home |
300 |
500 |
|
|
Tolmar |
Yes |
Home |
500 |
|
|
|
Veltassa |
Yes |
Home |
500 |
|
|
|
FPL=federal poverty limit SSN=social security number |
|||||
Programs that do NOT provide automatic refills: AbbVie, Boehringer Ingelheim, GSK, Novartis, Pfizer
Programs that needle request need indicated: Novo Nordisk (Lilly does NOT include needles)
Programs that require separate prescription be sent: GSK
Programs that require applications mailed in: Merck
Programs that send pharmacy card with ID, BIN, and Rx Group instead of medication itself: Johnson&Johnson for Xarelto
|
Income thresholds based on federal poverty limit (FPL)A 2022 |
||||||||
|
Household size |
100% ($) |
133% ($) |
150% ($) |
200% ($) |
250% ($) |
300% ($) |
400% ($) |
500% ($) |
|
1 |
13,590 |
18,075 |
20,385 |
27,180 |
33,975 |
40,770 |
54,360 |
67,950 |
|
2 |
18,310 |
24,352 |
27,465 |
36,620 |
45,775 |
54,930 |
73,240 |
91,550 |
|
3 |
23,030 |
30,630 |
34,545 |
46,060 |
57,575 |
69,090 |
92,120 |
115,150 |
|
4 |
27,750 |
36,908 |
41,625 |
55,500 |
69,375 |
83,250 |
111,000 |
138,750 |
|
5 |
32,470 |
43,185 |
48,705 |
64,940 |
81,175 |
97,410 |
129,880 |
162,350 |
|
6 |
37,190 |
49,463 |
55,785 |
74,380 |
92,975 |
111,570 |
148,760 |
185,950 |
|
7 |
41,910 |
55,740 |
62,865 |
83,820 |
104,775 |
125,730 |
167,640 |
209,550 |
|
8 |
46,630 |
62,018 |
69,945 |
93,260 |
116,575 |
139,890 |
186,520 |
233,150 |
|
Each additional |
4,720 |
6,278 |
7,080 |
9,440 |
11,800 |
14,160 |
18,880 |
23,600 |
|
A: Federal poverty limits are subject to change on an annual basis |
||||||||
Medications with PAP per drug
manufacturer
AADIAssist Patient Assistance Program
|
Eligibility |
||
|
US
resident |
<400% FPL |
Uninsured/Medicare |
|
Household
size |
Annual
household income ($) threshold (<400%
FPL) |
|
1 |
54,360 |
|
2 |
73,240 |
|
3 |
92,120 |
|
4 |
111,000 |
|
5 |
129,880 |
|
>5 |
Add 4,720 for each additional person |
|
Medications
eligible for assistance |
|
FYARRO (sirolimus albumin bound) for
injection |
AbbVie
Assist (usually reviewed within 2 business days)
|
Eligibility |
||
|
US resident |
Below income threshold |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold |
|
1 |
81,540 |
|
2 |
109,860 |
|
3 |
138,180 |
|
4 |
166,500 |
|
>5 |
Add 28,320 for each
additional person |
|
Proof of income |
Most recent federal tax form, W2, or social security
statements |
|
Medications eligible for assistance |
|
Acuvail
(ketorolac tromethamine) ophthalmic solution |
|
AeroChamber
Plus Flow-Vu |
|
Alloderm |
|
Alphagan P (brimonidine
tartrate) ophthalmic solution |
|
Armour
Thyroid (thyroid tablets, USP) tablets |
|
Avycaz
(avibactam/ceftazidime) |
|
BOTOX
(onabotulinumtoxinA) |
|
Bystolic
(nebivolol) tablets |
|
Canasa
(mesalamine) suppository |
|
Carafate
(sucralfate) oral suspension |
|
Combigan
(brimonidine tartrate/timolol maleate) ophthalmic solution |
|
CREON
(Pancrelipase) delayed-release capsules |
|
Crinone
(progesterone) gel |
|
Dalvance
(dalbavancin) lyophilizate |
|
Delzicol
(mesalamine DR) capsules |
|
Depakote
(divalproex sodium) |
|
Duopa
(carbidopa/levodopa) enteral suspension |
|
Durysta
(Bimatoprost) ocular implant |
|
Estrace
(estradiol) cream |
|
Fetzima
(Levomilnacipran) extended release capsules and titration pack |
|
Gelnique
(oxybutynin chloride 10%) gel |
|
GENGRAF
capsules (cyclosporine, USP [MODIFIED]) |
|
HUMIRA
(adalimumab) |
|
IMBRUVICA
(ibrutinib) |
|
Infed (iron
dextran) injection |
|
KALETRA
(lopinavir/ritonavir) |
|
Lexapro
(escitalopram) |
|
Liletta
(levonorgestrel) intrauterine contraceptive |
|
Linzess
(linaclotide) capsules |
|
Lo Lestrin
fe |
|
Lumigan
(Bimatoprost 0.01%) ophthalmic solution |
|
Lupron
Depot-Ped (leuprolide acetate for depot suspension) |
|
Lupron Depot
(leuprolide acetate for depot suspension) |
|
MAVYRET
(Glecaprevir/Pibrentasvir) |
|
Monurol
(Fosfomycin tromethamine) oral granules |
|
Namenda and
Namenda XR (memantine) |
|
Namzaric
(memantine extended release and donepezil) |
|
NATRELLE |
|
NORVIR
(ritonavir) tablets and oral solution |
|
Oriahnn
(Elagolix/estradiol/norethindrone) |
|
ORILISSA
(Elgaolix) tablets |
|
Ozurdex (dexamethasone)
ocular implant |
|
Pred Forte
(prednisolone acetate) ophthalmic suspension |
|
Pylera
(bismuth Subcitrate potassium, metronidazole, and tetracycline) capsules |
|
Qulipta
(Atogepant) tablets |
|
Rapaflo
(silodosin) capsules |
|
Rectiv
(nitroglycerin) ointment |
|
Restasis
(cyclosporine) ophthalmic emulsion |
|
RINVOQ
(upadacitinib) |
|
Saphris
(asenapine maleate) sublingual tablet |
|
Savella
(milnacipran) tablets |
|
SKYRIZI
(Risankizumab-rzaa) |
|
STRATTICE
(reconstructive tissue matrix) |
|
Synthroid (levothyroxine
sodium) tablets |
|
Teflaro
(ceftaroline fosamil) powder for injection |
|
Ubrelvy
(ubrogepant) tablets |
|
Venclexta
(venetoclax) tablets |
|
Viberzi
(eluxadoline) |
|
Viibryd
(vilazodone) |
|
Vraylar
(cariprazine) capsules |
|
Xen (gel
stent) |
Contact info-Phone:
1-800-222-6885 Fax: 1-866-898-1473
Acadia
Connect
|
Eligibility |
||
|
US resident |
Any income |
Uninsured/Medicare |
|
Medications
eligible for assistance |
|
NUPLAZID (pimavanserin) |
|
Eligibility |
||
|
US resident |
<550% FPL |
Uninsured/Medicare |
|
Medications
eligible for assistance |
|
Zynlonta (loncastuximab tesirine) |
AMGEN safety net program
|
Eligibility |
||
|
US resident >6 months |
<500%
FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<500% FPL) |
|
1 |
67,950 |
|
2 |
91,550 |
|
3 |
115,150 |
|
4 |
138,750 |
|
>5 |
Click for FPL for household larger than 5 or add 23,600 per each
additional person |
|
Medications eligible for assistance |
|
Aimovig
(erenumab) |
|
ARANESP
(darbepoetin alfa) |
|
AVSOLA
(infliximab-axxq) |
|
BLINCYTO (blinatumomab) |
|
Corlanor
(ivabradine) |
|
Enbrel
(etanercept) |
|
Epogen
(epoetin alfa) |
|
EVENITY
(romosozumab-aqqg) |
|
IMLYGIC
(talimogene) |
|
KANJINTI
(trastuzumab-anns) |
|
Kyprolis
(carilzomib) |
|
LUMAKRAS
(sotorasib) |
|
MVASI
(bevacizumab-awwb) |
|
Neulasta (pegfilgrastim) |
|
NEUPOGEN
(filgrastim) |
|
Nplate
(romiplostim) |
|
Otezla
(apremilast) |
|
Parsabiv
(etelcalcetide) |
|
Prolia
(denosumab) |
|
Repatha
(evolocumab) |
|
RIABNI
(rituximab-arrx) |
|
Sensipar
(cinacalcet) |
|
Vectibix
(panitumumab) |
|
XGEVA
(denosumab) |
Contact info varies by program, see individual medication application for phone and fax
|
Eligibility |
||
|
US resident |
< 300-500%
FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold |
|
|
Group 1 (< 300% FPL) |
Group 2 (<500% FPL) |
|
|
1 |
40,770 |
67,950 |
|
2 |
54,930 |
91,550 |
|
3 |
69,090 |
115,150 |
|
4 |
83,250 |
138,750 |
|
>5 |
Call AZ&ME
1-800-292-6363 |
|
|
Insurance
Group |
Medication
name |
|
1 |
BEVESPI
AEROSPHERE (glycopyrrolate/formoterol) |
|
1 |
BREZTRI
AEROSPHERE (budesonide/glycopyrrolate/formoterol) |
|
1 |
BRILINTA
(ticagrelor) |
|
1 |
BYDUREON
(exenatide extended release) |
|
1 |
BYETTA
(exenatide) |
|
2 |
CALQUENCE
(acalabrutinib) |
|
1 |
DALIRESP
(roflumilast) |
|
1 |
FARXIGA
(dapagliflozin) |
|
2 |
FASENRA
(benralizumab) |
|
2 |
FASENRA pen
(benralizumab) |
|
2 |
FALSODEX
(fulvestrant) |
|
2 |
IMFINZI
(durvalumab) |
|
2 |
IRESSA
(gefitinib) |
|
1 |
KOMBIGLYZE
ER (saxagliptin/metformin ER) |
|
2 |
KOSELUGO
(selumetinib) |
|
1 |
LOKELMA
(sodium zirconium cyclosilicate) |
|
2 |
LUMOXITI
(moxetumomab pasudotox-tdffk) |
|
2 |
LYNPARZA
(Olaparib) |
|
1 |
ONGLYZA
(saxagliptin) |
|
1 |
PULMICORT
FLEXHALER (budesonide) |
|
1 |
QTERN
(dapagliflozin/saxagliptin) |
|
2 |
SAPHNELO
(anifrolumab-fnia) |
|
1 |
SYMBICORT
(budesonide/formoterol) |
|
1 |
SYMLIN
(pramlintide) |
|
2 |
TAGRISSO (Osimertinib) |
|
1 |
XIGDUO XR
(dapagliflozin/metformin ER) |
Contact
info-Phone: 1-800-292-6363 Fax for non-specialty medications:
1-800-961-8323
Boehringer Ingelheim (BI Cares
Program)
|
Eligibility |
||
|
US resident |
<250% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<250% FPL) |
|
1 |
33,975 |
|
2 |
45,775 |
|
3 |
57,575 |
|
4 |
69,375 |
|
5 |
81,175 |
|
Medications eligible for assistance |
|
Aptivus (tipranavir) |
|
Atrovent HFA (ipratropium) |
|
COMBIVENT Respimat (ipratropium/albuterol) |
|
GILTORIF
(afatinib)$ |
|
Glyxambi (empaglizoin/metformin) |
|
Jardiance (empagliflozin) |
|
Jentadueto & Jentadueto XR
(linagliptin/metformin) |
|
OFEV
(nintedanib)$ |
|
Pradaxa (dabigatran) |
|
Spiriva Handihaler or Respimat (tiotropium) |
|
Stiolto Respimat
(tiotropium/olodaterol) |
|
Striverdi Respimat (olodaterol) |
|
Synjardy & Synjardy XR
(empagliflozin/metformin) |
|
Tradjenta (linagliptin) |
|
Trijardy XR
(empagliflozin/linagliptin/metformin) |
|
Viramune XR (nevirapine) |
|
$ Has individual application |
Contact
info: Phone: 1-800-556-8317 Fax:
1-866-851-2827
|
Eligibility |
||
|
US resident |
< 300% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<300% FPL) |
|
1 |
40,770 |
|
2 |
54,930 |
|
3 |
69,090 |
|
4 |
83,250 |
|
5 |
97,410 |
|
Each additional person |
14,160 |
|
Medications eligible for assistance |
|
ABRAXANE® (paclitaxel
protein-bound particles for injectable suspension (albumin-bound)) |
|
ELIQUIS® (apixaban) |
|
EMPLICITI® (elotuzumab) |
|
IDHIFA® (Enasidenib) |
|
INREBIC® (fedratinib) |
|
ISTODAX® (Romidepsin) |
|
NULOJIX® (belatacept)) |
|
ONUREG® (azactidine
tablets) |
|
OPDIVO® (nivolumab) |
|
OPDUALAG™ (nivolumab
and relatlimab – rmbw) |
|
ORENCIA® (Abatacept) |
|
POMALYST® (pomalidomide) |
|
REBLOZYL® (luspatercept-aamt) |
|
REVLIMID® (lenalidomide) |
|
SPRYCEL® (dasatinib) |
|
THALOMID® (thalidomide) |
|
VIDAZA® (azacitidine
for injection) |
|
YERVOY® (Ipilimumab) |
|
ZEPOSIA® (ozanimod) |
Application
for Eliquis, Nulojix, and Orencia are the same
Contact
info-Phone: 1-800-736-0003 Fax: 1-800-736-1611 Fax 2:
833-967-1666
|
Eligibility |
||
|
US resident |
< 250% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<250% FPL) |
|
1 |
33,975 |
|
2 |
45,774.96 |
|
3 |
57,575.04 |
|
4 |
69,375 |
|
>5 |
Add 11,859.96 |
|
Medications eligible for assistance |
|
ADVAIR (diskus or HFA) (Fluticasone/salmeterol) |
|
ANORO ELLIPTA (Umeclidinium/vilanterol) |
|
ARNUITY ELLIPTA (Fluticasone) |
|
BECONASE AQ
(Beclomethasone dipropionate nasal spray) |
|
BENLYSTA
(Belimumab) |
|
BLENREP (Belantamab) |
|
BOOSTRIX (Tdap vaccine) |
|
BREO ELLIPTA (Fluticasone/vilanterol) |
|
EPIVIR-HBV (Lamivudine solution or tablets) |
|
ENGERIX-B (Hepatitis B vaccine) |
|
FLOVENT (diskus or HFA) (Fluticasone) |
|
IMITREX (Sumatriptan nasal spray) |
|
INCRUSE ELLIPTA (Umeclidinium) |
|
JEMPERLI (Dostarlimab) |
|
LAMICTAL (Lamotrigine chewable or orally
disintegrating tablets) |
|
LAMICTAL ODT (Lamotrigine patient titration kits) |
|
LAMICTAL XR (Lamotrigine ER or patient titration
kit) |
|
MALARONE (Atovaquone and proguanil ) |
|
MEPRON (Atovaquone suspension) |
|
NUCALA (Mepolizumab) |
|
RELENZA (Zanamivir inhalation powder) |
|
SEREVENT (diskus) (Salmeterol) |
|
SHINGRIX
(Zoster vaccine) |
Contact
info: Phone:1-866-728-4368 Fax: 1-855-474-3063
Johnson & Johnson
|
Eligibility |
||
|
US resident |
< 300-600% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold |
||
|
Group 1 (< 300% FPL) |
Group 2 (<400% FPL) |
Group 3 (<600% FPL) |
|
|
1 |
40,770 |
54,360 |
81,540 |
|
2 |
54,930 |
73,240 |
109,860 |
|
3 |
69,090 |
92,120 |
138,180 |
|
4 |
83,250 |
111,000 |
166,500 |
|
>5 |
Call Johnson & Johnson
1-800-652-6227 |
||
|
Insurance group |
Medication name |
|
3 |
BALVERSA (erdafitinib) tablets |
|
3 |
DARZALEX (daratumumab) injection for IV
infusion |
|
3 |
DARZALEX FASPRO (daraumumab and
hyaluronidase-fihj) injection for subcutaneous use |
|
1 |
EDURANT (rilpivirine) tablets |
|
1 |
ELMIRON (pentosan polysulfate sodium)
capsules |
|
3 |
ERLEADA (paludomid) tablets |
|
1 |
HALDOL Decanoate (haloperidol) IM
injection only |
|
3 |
IMBRUVICA (ibrutinib) capsules/tablets |
|
1 |
INTELENCE (etravirine) tablets |
|
1 |
INVEGA SUSTENNA, TRINZA and HAFYERA
(paliperidone palmitate) extended-release injection |
|
1 |
INVOKAMET (canagliflozin/metformin) |
|
1 |
INVOKAMET XR (canagliflozin/metformin
XR) |
|
1 |
INVOKANA (canagliflozin) |
|
2 |
MONOVISC (high molecular weight
hyaluronan) injection |
|
2 |
OPSUMIT (macitentan) tablets |
|
2 |
ORTHOVISC (high molecular weight
hyaluronan) injection |
|
2 |
PONVORY (ponesimod) |
|
1 |
PREZCOBIX (darunavir/cobicistat) |
|
1 |
PREZISTA (darunavir) |
|
2 |
PROCRIT (epoetin alfa) |
|
3 |
REMICADE (infliximab) IV infusion |
|
1 |
RISPERDAL CONSTA (risperidone)
long-acting injection |
|
3 |
RYBREVANT (amivantamab-vmjw) |
|
3 |
SIMPONI (golimumab) injection |
|
1 |
SIRTURO (bedaquiline) tablets |
|
1 |
SPORANOX (itraconazole) capsules and
oral solution |
|
1 |
SPRAVATO (esketamine) nasal spray
[CIII] |
|
3 |
STELARA (ustekinumab) for subcutaneous
or IV use |
|
1 |
SYMTUZA (darunavir, cobicistat,
emtricitabine, tenofovir alafenamide) tablets |
|
3 |
TRACLEER (bosentan) |
|
3 |
TREMFYA (guselkumab) for subcutaneous
use |
|
3 |
UPTRAVI (selexipag) |
|
3 |
VELETRI (epoprostenol) |
|
3 |
VENTAVIS (iloprostol) |
|
1 |
XARELTO (rivaroxaban) tablets or oral
solution |
|
3 |
YONDELIS (trabectedin) for IV infusion |
|
3 |
ZYTIGA (abiraterone) tablets |
Contact
info-Phone: 1-800-652-6227 Fax: 1-888-526-5168
Lilly Cares Program
|
Eligibility |
||
|
US resident |
< 300-500% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold |
||
|
Group 1 (< 300% FPL) |
Group 2 (<400% FPL) |
Group 3 (<500% FPL) |
|
|
1 |
40,770 |
54,360 |
67,950 |
|
2 |
54,930 |
73,240 |
91,550 |
|
3 |
69,090 |
92,120 |
115,150 |
|
4 |
83,250 |
111,000 |
138,750 |
|
>5 |
Call Lilly cares
1-800-545-6962 |
||
|
Insurance
Group |
Medication
name |
Package insert |
Patient education |
|
3 |
Alimta® (pemetrexed for injection) |
||
|
2 |
Baqsimi® (glucagon) nasal powder |
||
|
2 |
Basaglar® (insulin glargine injection) |
||
|
2 |
Cialis® (tadalafil) tablets |
||
|
1 |
Cymbalta® (duloxetine delayed-release capsules) |
||
|
3 |
Cyramza® (ramucirumab) injection |
||
|
2 |
Emgality® (galcanezumab-gnlm) injection |
||
|
3 |
Erbitux® (cetuximab) injection |
||
|
1 |
Evista® (raloxifene hydrochloride) Tablet |
||
|
1 |
Forteo® (teriparatide injection) |
||
|
2 |
Glucagon™ (glucagon for injection) |
||
|
2 |
Humalog® U-100 (insulin lispro injection) |
||
|
2 |
Humalog® U-200 (insulin lispro injection) |
||
|
2 |
Humalog® Mix50/50™ (insulin
lispro protamine and insulin lispro injectable suspension) |
||
|
2 |
Humalog® Mix75/25™ (insulin
lispro protamine and insulin lispro injectable suspension) |
||
|
3 |
Humatrope® (somatropin) for injection |
||
|
2 |
Humulin® 70/30 (human insulin isophane suspension and
human insulin injection) |
||
|
2 |
Humulin® N (isophane insulin human suspension) |
||
|
2 |
Humulin® R (insulin human injection) |
||
|
2 |
Humulin® R U-500 (insulin human injection) |
||
|
2 |
Lyumjev™ (insulin lispro-aabc) injection |
||
|
3 |
Olumiant® (baricitinib) tablets |
||
|
3 |
Portrazza® (necitumumab) injection |
||
|
1 |
Prozac® (fluoxetine capsules) |
||
|
3 |
Retevmo™ (selpercatinib) capsules |
||
|
2 |
Reyvow® (lasmiditan) tablets C-V |
||
|
1 |
Strattera® (atomoxetine) capsules |
||
|
1 |
Symbyax® (olanzapine and fluoxetine) capsules |
||
|
3 |
Taltz® (ixekizumab) injection |
||
|
2 |
Trulicity® (dulaglutide) injection |
||
|
3 |
Verzenio® (abemaciclib) tablets |
||
|
1 |
Zyprexa® (olanzapine) Tablet |
||
|
1 |
Zyprexa® Zydis® (olanzapine)
Tablet |
||
Contact
info-Phone: 1-800-545-6962 Fax: 1-844-431-6650
Merck and Co – Merck Helps: patient
assistance program
|
Eligibility |
||
|
US resident |
< 400% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<400% FPL) |
|
1 |
54,360 |
|
2 |
73,240 |
|
3 |
92,120 |
|
4 |
111,000 |
|
5 |
129,880 |
|
>5 |
Add 4,720 for each
additional person |
1.
|
BELSOMRA® (suvorexant) C-IV |
|
CANCIDAS® (caspofungin acetate) for Injection |
|
DELSTRIGO™ (doravirine, lamivudine, and tenofovir disoproxil
fumarate) tablets, for oral use |
|
DIFICID® (fidaxomicin) tablets |
|
DIFICID® (fidaxomicin) for oral suspension 40 mg/mL |
|
EMEND® (aprepitant) for Oral Suspension 125 mg |
|
EMEND® (aprepitant) 80 mg, 125 mg capsules |
|
EMEND® (fosaprepitant dimeglumine) for Injection 150 mg |
|
GARDASIL®9 (Human Papillomavirus 9-valent Vaccine,
Recombinant) |
|
ISENTRESS® (raltegravir) 400 mg film-coated and 25 mg and
100 mg chewable Tablets |
|
ISENTRESS® HD (raltegravir) 600 mg Tablets |
|
ISENTRESS® OS (raltegravir) 100 mg Granules for
Suspension |
|
JANUMET® (sitagliptin and metformin HCI) Tablets |
|
JANUMET® XR (sitagliptin and metformin HCI extended-release)
Tablets |
|
JANUVIA® (sitagliptin) Tablets |
|
KEYTRUDA® (pembrolizumab) Injection [liquid formulation]
100 mg |
|
M-M-R® II (Measles, Mumps, and Rubella Virus Vaccine
Live) |
|
NOXAFIL® (posaconazole) oral suspension, 40 mg/mL |
|
NOXAFIL® (posaconazole) delayed-release tablets 100 mg |
|
PIFELTRO™ (doravirine) tablets, for oral use |
|
PNEUMOVAX®23 (Pneumococcal Vaccine Polyvalent) |
|
PREVYMIS™ (letermovir) 240 mg Tablets |
|
RECARBRIO™ (imipenem, cilastatin, and relebactam) for
injection, for intravenous use |
|
RECOMBIVAX HB® [Hepatitis B Vaccine (Recombinant)] |
|
STROMECTOL® (ivermectin) Tablets |
|
TRUSOPT® (dorzolamide hydrochloride ophthalmic solution)
2% |
|
VAQTA® (Hepatitis A Vaccine, Inactivated) |
|
VARIVAX® (Varicella Virus Vaccine Live) |
|
VAXNEUVANCE™ (Pneumococcal 15-valent conjugate vaccine) |
|
VERQUVO™ (vericiguat) 2.5 mg, 5 mg, 10 mg tablets |
|
WELIREG™ (belzutifan) 40 mg Tablets |
|
ZEPATIER® (elbasvir and grazoprevir) |
|
ZERBAXA™ (ceftolozane and tazobactam) for Injection for Intravenous
Use |
|
ZINPLAVA™ (bezlotoxumab) Injection 25 mg/ml |
|
ZOLINZA® (vorinostat) 100 mg Capsules |
Contact
info-Phone: 1-800-727-5400
MyPraluent Patient Assistance Program
|
Eligibility |
||
|
US resident |
>135% <
300% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<300% FPL) |
|
1 |
40,770 |
|
2 |
54,930 |
|
3 |
69,090 |
|
4 |
83,250 |
|
>5 |
Contact Radius program at
1-844-772-5836 |
|
Medication eligible for assistance |
|
Praluent (alirocumab) |
Contact
info-Phone:1-844-772-5836 Fax: 1-844-855-7278
Mylan pharmaceuticals now Viatris
|
Eligibility |
||
|
US resident |
< 400-500% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold |
|
|
Group 1 & 2 medications <400% FPL |
Fulphila & Ogivri (<500% FPL) |
|
|
1 |
54,360 |
67,950 |
|
2 |
73,240 |
91,550 |
|
3 |
92,120 |
115,150 |
|
4 |
111,000 |
138,750 |
|
5 |
129,880 |
162,350 |
|
>5 |
Add 23,600 for each
additional person in household |
|
|
Insurance
Group |
Medication
name |
|
1 |
Arixtra (fondaparinux) |
|
2 |
Caduet (amlodipine/atorvastatin) |
|
1 |
Cimduo (lamivudine/tenofovir disoproxil fumarate) tablet |
|
1 |
Clozapine |
|
1 |
Cortifoam (hydrocortisone 10%) rectal foam |
|
1 |
Cystagon (cysteamine) capsules |
|
1 |
Denavir (penciclovir) cream 1% |
|
1 |
Depen (penicillamine) tablets |
|
2 |
Detrol LA (tolterodine) |
|
1 |
Dipentum (olsalazine) capsule |
|
1 |
Dymista (azelastine/fluticasone) nasal spray |
|
1 |
Elestrin (estradiol gel) 0.06% |
|
1 |
Emsam transdermal system |
|
2 |
EpiPen & EpiPen Jr
(epinephrine) injection |
|
1 |
Erygel (erythromycin) topical gel 2% |
|
1 |
Evoclin (clindamycin) foam 1% |
|
1 |
Felbatol (felbamate) |
|
2 |
Fulphila (pegfilgastrim-jmdb)* |
|
1 |
Gastrocrom (cromolyn) oral concentrate |
|
2 |
Glatiramer
Acetate |
|
1 |
Impeklo (clobetasol) lotion |
|
2 |
Inspra (eplerenone) |
|
1 |
Luxiq (betamethasonevalerate) foam |
|
1 |
Miacalcin injection (calcitonin) |
|
1 |
Muse (alprostadil) urethral |
|
2 |
Ogivri* (trastuzumab-dkst) |
|
1 |
Olux (clobetasol) foam 0.05% |
|
1 |
Olux-E (clobetasol) foam 0.05% |
|
1 |
Perforomist (formoterol fumarate) inhalation solution |
|
1 |
Pretomanid tablet |
|
1 |
Proctofoam
HC (hydrocortisone acetate 1% & pramoxine 1%) |
|
2 |
Relpax (eletriptan) |
|
1 |
Rowasa (mesalamine) rectal suspension |
|
1 |
Semglee (insulin glargine) |
|
1 |
SF Rowasa (mesalamine) rectal suspension |
|
2 |
Tobi (tobramycin) ampules or podhalers |
|
1 |
Wixela (fluticasone/salmeterol) |
|
1 |
Xulane (norelgestromin and ethinyl estradiol transdermal
system) |
|
1 |
Yupelri (revefenacin) |
|
*FPL
threshold 500% |
|
Contact
info-Phone: 888-417-5780 Fax:
877-427-7290
Nestle Health Science Patient
assistance program
|
Eligibility |
||
|
US resident |
< 400% FPL |
Uninsured |
|
Household size |
Annual household income ($) threshold (<400% FPL) |
|
1 |
54,360 |
|
2 |
73,240 |
|
3 |
92,120 |
|
4 |
111,000 |
|
5 |
129,880 |
|
>5 |
Add 4,720 for each
additional person |
|
Medication eligible for assistance |
|
Viokace (pancrelipase) tablets |
|
Zenpep (pancrelipase) delayed release
capsule |
Contact
info-Phone: 1-855-210-6228 Fax: 1-877-867-1831
Novartis Patient Assistance
Foundation
|
Eligibility |
||
|
US resident |
Below annual
income threshold |
Uninsured |
|
Household size |
Annual household income ($) threshold |
|
1 |
70,000 |
|
2 |
100,000 |
|
3 |
125,000 |
|
4 |
150,000 |
|
>5 |
Add 25,000 per additional
person |
|
Adakveo® (crizanlizumab-tmca) |
|
Afinitor® (everolimus) |
|
Afinitor Disperz® (everolimus suspension) |
|
Alomide® (lodoxamide tromethamine solution) |
|
Beovu® (brolucizumab-dbll) Injection |
|
Betoptic S® (betaxolol hydrochloride suspension) |
|
Coartem® (artemether and lumefantrine) |
|
Cosentyx® (secukinumab) |
|
Entresto™ (sacubitril/valsartan) |
|
Extavia® (interferon beta-1b) |
|
Ferumoxytol injection |
|
Fulvestrant injection, for intramuscular use |
|
Gilenya® (fingolimod) |
|
Hycamtin® (topotecan) Capsules |
|
Hycamtin® (topotecan hydrochloride) For Injection |
|
Ilaris® (canakinumab) |
|
Ilevro® (nepafenac suspension) |
|
Jadenu ® (deferasirox) |
|
Jadenu® Sprinkle (deferasirox) granules |
|
Kesimpta® (ofatumumab) |
|
Kisqali® (ribociclib) |
|
Kisqali® Femara® Co-Pack (ribociclib and letrozole) tablets |
|
Leqvio® (Inclisiran) |
|
Lutathera® (lutetium Lu 177 dotatate) |
|
Levoleucovorin Injection |
|
Maxidex® (dexamethasone suspension) |
|
Mayzent® (Siponimod) |
|
Mekinist® (trametinib) |
|
Nevanac® (nepafenac suspension) |
|
Omnitrope® Somatropin (rDNA origin) |
|
Piqray® (alpelisib) |
|
Pluvicto® (177Lu-PSMA-617) |
|
Promacta® (eltrombopag) |
|
RYDAPT® (midostaurin) |
|
SANDOSTATIN LAR® DEPOT (octreotide acetate) |
|
Scemblix® (asciminib) Tablets |
|
Tabrecta™ (capmatinib) |
|
Tafinlar® (dabrafenib) |
|
Tasigna® (nilotinib) |
|
Tobradex® (ophthalmic ointment) |
|
Triesence® (triamcinolone acetonide injectable suspension) |
|
Tykerb® (lapatinib) |
|
Vijoice® (alpelisib) |
|
Votrient® (pazopanib) |
|
Xiidra® (lifitegrast ophthalmic solution) |
|
Zarxio™ (filgrastim-sndz) |
|
Ziextenzo® (pegfilgrastim-bmez) |
|
ZYKADIA® (ceritinib) |
Contact
info-Phone: 1-800-277-2254 Fax: 1-855-817-2711
Novo Nordisk (up to 10 days for
processing)
|
Eligibility |
||
|
US resident |
<
400% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<400% FPL) |
|
1 |
54,360 |
|
2 |
73,240 |
|
3 |
92,120 |
|
4 |
111,000 |
|
5 |
129,880 |
|
>5 |
Add 4,720 for each
additional person |
Medications are sent to primary care office if approved
|
Fiasp Flextouch (insulin aspart)* |
|
GlucaGen Hypokit |
|
Levemir (insulin detemir) Flextouch* |
|
Novolin N vial (insulin NPH) |
|
Novolin 70/30 (insulin NPH and insulin R mix) vial |
|
Novolin R vial (insulin regular) |
|
Novolog (insulin aspart) FlexPen* |
|
Novlog mix 70/30 (insulin aspart protamine and insulin aspart)
FlexPen* |
|
Ozempic (semaglutide) injection* |
|
Rybelsus (semalgutide) tablets |
|
Tresiba (insulin degludec) FlexTouch* |
|
Victoza (liraglutide) pen* |
|
Xultophy (insulin degludec & liraglutide) pen* |
|
*Request Novo Nordisk disposable needles on
prescription/application or they will not be sent |
Contact
info- Phone: 1-866-310-7549 Fax: 1-866-441-4190
Otsuka Patient Assistance Foundation
|
Eligibility |
||
|
US resident |
< 300-700% FPL |
Uninsured |
|
Household size |
Annual household income ($) threshold |
|
|
All other medications (< 300% FPL) |
Jynarque (<700% FPL) |
|
|
1 |
40,770 |
109,860 |
|
2 |
54,930 |
138,180 |
|
3 |
69,090 |
166,500 |
|
4 |
83,250 |
Add 28,320 |
|
>5 |
Call Otsuka 1-855-727-6274 |
|
|
Medications available for assistance |
|
Abilify
Maintena (aripiprazole) for extended release injectable suspension |
|
Jynarque
(tolvaptan) tablets |
|
Rexulti
(Brexpiprazole) tablets |
|
Samsca
(tolvaptan) |
Contact
info-Phone: 1-8555-727-6274 Fax: 1-844-727-6274
Pfizer RxPathways patient assistance
program (2-3 weeks for processing)
|
Eligibility |
||
|
US resident |
< 400% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold |
|
|
Non-B medications <400% FPL |
Group B |
|
|
1 |
54,360 |
49,960 |
|
2 |
73,240 |
67.640 |
|
3 |
92,120 |
85,320 |
|
4 |
111,000 |
103,00 |
|
5 |
129,880 |
120,680 |
|
>5 |
Call Pfizer program
1-866-706-2400 |
|
|
Insurance
Group |
Medication
name |
|
B |
VFEND® (voriconazole) |
|
B |
Revatio
(sildenafil) |
|
B |
RAPAMUNE® (sirolimus) |
|
Non-B medications |
AROMASIN® (exemestane) tablets |
|
ARTHROTEC® (diclofenac sodium/misoprostol) tablets |
|
|
BeneFIX® Coagulation Factor IX (Recombinant) |
|
|
BESPONSA™ (inotuzumab ozogamicin, for injection, for intravenous use)
|
|
|
BOSULIF® (bosutinib) tablets |
|
|
CADUET® (amlodipine besylate/atorvastatin calcium) tablets |
|
|
CAMPTOSAR® (irinotecan hydrochloride) injection |
|
|
CAVERJECT® (alprostadil) injection CAVERJECT® Impulse®
(alprostadil) injection |
|
|
CELEBREX® (celecoxib) capsules |
|
|
CELONTIN® (methsuximide) capsules, USP |
|
|
CHANTIX® (varenicline) tablets |
|
|
CIBINQO™ (abrocitinib) tablets |
|
|
DAURISMO™ (glasdegib) tablets |
|
|
DEPO-PROVERA® (medroxyprogesterone acetate
injectable suspension) |
|
|
DEPO®-ESTRADIOL (estradiol cypionate) injection, USP |
|
|
DETROL® (tolterodine tartrate) tablets |
|
|
DETROL® LA (tolterodine tartrate) extended-release capsules |
|
|
DILANTIN® (extended phenytoin sodium) capsules |
|
|
DUAVEE™ (conjugated estrogens/bazedoxifene) tablets |
|
|
ELLENCE® (epirubicin hydrochloride injection) |
|
|
EMCYT® (estramustine phosphate sodium) capsules |
|
|
ESTRING® (estradiol vaginal ring) |
|
|
FELDENE® (piroxicam) capsules |
|
|
FRAGMIN® (dalteparin sodium) injection |
|
|
GENOTROPIN® (somatropin) for injection |
|
|
HEPARIN Sodium Injection, USP |
|
|
IBRANCE® (palbociclib) capsules
|
|
|
IDAMYCIN PFS® (idarubicin hydrochloride) injection |
|
|
INFLECTRA® (infliximab-dyyb) for injection |
|
|
INLYTA® (axitinib) tablets |
|
|
INSPRA® (eplerenone) tablets |
|
|
LEVOXYL® (levothyroxine sodium)
tablets |
|
|
LINCOCIN® (lincomycin) injection, USP |
|
|
LORBRENA® (lorlatinib) tablets |
|
|
MENEST® (esterified estrogens) tablets,
USP |
|
|
MYCOBUTIN® (rifabutin) capsules, USP |
|
|
MYLOTARG™ (gemtuzumab ozogamicin) for injection |
|
|
NICOTROL® (nicotine) |
|
|
NIVESTYM® (filgrastim-aafi) injection |
|
|
NORPACE® (disopyramide phosphate) |
|
|
PREMARIN® (conjugated estrogens) tablets, USP (conjugated estrogens tablets |
|
|
PREMARIN® (conjugated estrogens) Vaginal Cream (conjugated estrogens) Vaginal Cream |
|
|
PREMPRO® (conjugated estrogens/medroxyprogesterone
acetate) tablets |
|
|
PREMPHASE® (conjugated estrogens plus medroxyprogesterone acetate) tablets |
|
|
PREVNAR 13® Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein] |
|
|
PRISTIQ® (desvenlafaxine) extended-release tablets |
|
|
RELPAX® (eletriptan hydrobromide) tablets |
|
|
RETACRIT® (epoetin alfa-epbx) injection |
|
|
SKELAXIN® (metaxalone) tablets |
|
|
SOMAVERT® (pegvisomant) for injection |
|
|
SUTENT® (sunitinib malate) capsules |
|
|
SYNAREL® (nafarelin acetate) nasal solution |
|
|
TALZENNA® (talazoparib) capsules |
|
|
TIKOSYN® (dofetilide) capsules |
|
|
TORISEL® (temsirolimus) injection |
|
|
TOVIAZ® (fesoterodine fumarate) extended-release tablets |
|
|
TRECATOR® (ethionamide) tablets |
|
|
TRUMENBA® (Meningococcal Group B Vaccine) |
|
|
TYGACIL® (tigecycline) for injection |
|
|
VIZIMPRO® (dacomitinib) tablets |
|
|
VYNDAQEL® (tafamidis meglumine) capsules |
|
|
XALKORI® (crizotinib) capsules |
|
|
XANAX® CIV (alprazolam) tablets |
|
|
XELJANZ® (tofacitinib) tablets |
|
|
XELJANZ® (tofacitinib) oral solution |
|
|
XELJANZ® XR (tofacitinib) extended-release tablets |
|
|
XYNTHA® Antihemophilic Factor (Recombinant) |
|
|
ZARONTIN® (ethosuximide) ZYVOX® (linezolid) |
|
|
|
ZYVOX® (linezolid) |
Contact
info-Phone: 1-866-706-2400 Fax: 1-866-470-1748
Pfizer Oncology Together
|
Eligibility |
||
|
US resident |
< 500% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<500% FPL) |
|
1 |
67,950 |
|
2 |
91,550 |
|
3 |
115,150 |
|
4 |
138,750 |
|
>5 |
Click for FPL for household larger than 5 or add 23,600 per each
additional person |
|
AROMASIN (exemestane) |
|
BOSULIF (bosutinib) |
|
BRAFTOVI (encoarfenib) |
|
DAURISMO (glasdegib) |
|
EMCYT (estramustine) |
|
IBRANCE (Palbociclib) |
|
INLYTA (axitinib) |
|
LORBRENA (lorlatinib) |
|
MEKTOVI (bibimetinib) |
|
SUTENT (sunitinib) |
|
TALZENNA (talazoparib) |
|
VIZIMPRO (dacaomitinib) |
|
XALKORI (crizotinib) |
|
BESPONSA (inotuzumab) |
|
CAMPTOSAR (irinotecan) |
|
ELLENCE (epirubicin) |
|
IDAMYCIN (idarubicin) |
|
MYLOTARG (gemtuzumab) |
|
TORISEL (temsirolimus) |
|
NIVESTYM (filgrastim-aafi) |
|
NYVEPRIA (pegfilgrastim-apgf) |
|
RETACRIT (epoetin alfa-epbx) |
|
RUXIENCE (rituximab-pvvr) |
|
TRAZIMERA (trastuzumab-qyyp) |
|
ZIRABEV (bevacizumab-bvzr) |
Contact
info-Phone: 1-877-744-5675 Fax:
1-877-736-6506
|
Eligibility |
||
|
US resident |
< 300% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<300% FPL) |
|
1 |
40,770 |
|
2 |
54,930 |
|
3 |
69,090 |
|
4 |
83,250 |
|
>5 |
Contact Radius program at
1-866-896-5674 |
|
Medication eligible for assistance |
|
TYMLOS (abaloparatide) injection |
Contact
info-Phone: 1-866-896-5674 Fax: 1-800-910-4610
Program eligibility
1. Uninsured making <$150,000
2. Insured patients as follows:
|
Household size |
Annual household income ($) threshold |
|
1 |
<75,000 |
|
2 |
<100,000 |
|
3 |
<125,00 |
|
4 |
<150,000 |
|
>5 |
Add 25,000 for each
additional person |
|
Actemra (tocilizumab)1 |
|
Activase (alteplase) |
|
Alcensa (alectinib) |
|
Avastin (bevacizumab) |
|
Cathflo Activase (alteplase) |
|
Cotellic (cobimetinib) |
|
Enspryng (satralizumab-mwge) |
|
Erivedge (vismodegib) |
|
Esbriet (pirfenidone) |
|
Evrysdi (risdiplam) |
|
Gavreto (pralsetinib) |
|
Gazyva (Obinutuzumab) |
|
Hemlibra (emcizumab-kxwh) |
|
Herceptin (trastuzumab) |
|
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) |
|
Kadcyla (ado-trastuzumab emtansine) |
|
Lucentis (ranibizumab injection) |
|
Ocrevus (orelizumab) |
|
Pegasys (peginterferon alfa-2a) |
|
Perjeta (pertuzumab) |
|
Phesgo (pertuzumab, trastuzumab, and
hyaluronidase-zzxf) |
|
Polivy (polatuzumab vedotin-piiq) |
|
Pulmozyme (dornade alfa) inhalation
solution |
|
Rituxan (rituximab) for rheumatoid
arthritis1 |
|
Rituxan (rituximab) for oncology |
|
Rituxan (rituximab) for granulomatosis
with polyangiitis (GPA), microscopic polyangiitis (MPA) or pemphigus vulgaris
(PV) |
|
Rituxan hycela (rituximab/hyaluronidase
human) |
|
Rozlytrek (entrectinib) |
|
Susvimo (ranibizumab) |
|
Tecentriq (atezolizumab) |
|
TNKase (Tenecteplase) |
|
Vabysmo (faricimab-svoa) |
|
Venclexta (venetoclax tablets) |
|
Xeloda (capecitabine) |
|
Xolair (omalizumab) |
|
Zelboraf (vemurafenib) |
|
1. $5.00 copay, up to $15,000 in assistance annually for drug
costs and up to $2,000 in infusion assistance |
**Additional programs for Cellcept, Evrysdi, Valcyte, Fuzeon, Nutropin available***
Contact
info-Phone:(888)-941-3331 Fax: (833)-999-4363
Sanofi patient connection program (5-7 days medication sent directly to primary care provider office)
|
Eligibility |
||
|
US resident |
< 400% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<400% FPL) |
|
1 |
54,360 |
|
2 |
73,240 |
|
3 |
92,120 |
|
4 |
111,000 |
|
5 |
129,880 |
|
>5 |
Add 4,720 for each
additional person |
|
Adacel® (tetanus toxoid, reduced
diphtheria toxoid and acellular pertussis vaccine adsorbed) |
|
Admelog® (insulin lispro injection) 100
Units/mL |
|
Apidra® (insulin glulisine injection)
100 Units/mL |
|
Imogam® Rabies-HT Immune Globulin,
[Human] USP, Heat Treated |
|
Imovax® Rabies Vaccine [Human Diploid
Cell] |
|
Lantus® (insulin glargine injection)
100 Units/mL |
|
Lovenox® (enoxaparin sodium injection)1 |
|
MenQuadfi® (Meningococcal [Groups A, C,
Y, W] Conjugate Vaccine) |
|
Mozobil® (plerixafor injection)1 |
|
Multaq® (dronedarone) Tablets |
|
Pentacel®
Diptheria and Tetanus Toxoids and Acellular Pertussis Adsorbed, Inactivated
Poliovirus and Haemophilus b Conjugate (Tetanus Toxoid Conjugate) Vaccine |
|
Priftin® (rifapentine) Tablets |
|
Soliqua® 100/33 (insulin glargine &
lixisenatide) injection 100 Units/mL and 33 mcg/mL |
|
Tenivac® (tetanus and diphtheria
toxoids adsorbed |
|
Thymoglobulin® [Anti-Thymocyte Globulin (Rabbit)1 |
|
Toujeo® (insulin glargine injection) 300 Units/mL
(1.5 mL or 3.0 mL pens)2 |
|
1. if applying for Drug Replacement (Lovenox®, Mozobil®, and Thymoglobulin®), a copy of the claim, denial, flow sheet(s) and drug dispensing log (with patient name, date of service, product NDC/Lot #, total dosage) must be submitted 2. Regular SoloStar® is packaged as 3 pens per pack 450 units/pen; dials up to 80 units per single injection. Max SoloStar® is packaged as 2 pens per pack 900 units/pen; dials up to 160 units per single injection; Max pen dials in 2-unit increments |
Contact
info-Phone: 1-888-847-4877 Fax: 1-888-847-4797
Sunovion Prescription Assistance
Program
|
Eligibility |
||
|
US resident |
< 300% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<300% FPL) |
|
1 |
40,770 |
|
2 |
54,930 |
|
3 |
69,090 |
|
4 |
83,250 |
|
Medications eligible for assistance |
|
Aptiom®
(eslicarbazepine acetate) |
|
Kynmobi™
(apomorphine hydrochloride) |
|
Latuda
(lurasidone) |
Contact
info-Phone: 877-850-0819 Fax: 877-850-0821
|
Eligibility |
||
|
US resident |
< 500% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<500% FPL) |
|
1 |
67,950 |
|
2 |
91,550 |
|
3 |
115,150 |
|
4 |
138,750 |
|
>5 |
Click for FPL for household larger than 5 or add 23,600 per each
additional person |
|
Medications eligible for assistance |
|
Amitiza (lubiprostone) |
|
Carbatrol (carbamazepine extended-release) capsules |
|
Colcrys (colchicine) tablets |
|
Dexilant (dexlansoprazole) DR capsules |
|
Fosrenol (lanthanum carbonate) |
|
Intuniv (guanfacine) ER tablets |
|
Kazano (alogliptin/metformin) tablets |
|
Lialda (mesalamine) DR tablets |
|
Motegrity (prucalopride) tablets |
|
Mydayis (amphetamine) ER capsules |
|
Nesina (alogliptin) tablets |
|
Oseni (alogliptin/pioglitazone) tablets |
|
Pentasa (mesalamine) ER capsules |
|
Prevacid (lansoprazole) ODT tablets |
|
Rozerem (ramelteon) tablets |
|
Trintellix (vortioxetine tablets) |
|
Vyvanse (lisdexamfetamine) capsules and tablets |
Contact info-Phone: 1-800-830-9159 Fax: 1-800-497-0928
|
Eligibility |
||
|
US resident |
<300 - 500% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold |
|
|
Non-oncology medications <300% FPL |
Oncology medications <500% FPL |
|
|
1 |
40,770 |
67,950 |
|
2 |
54,930 |
91,550 |
|
3 |
69,090 |
115,150 |
|
4 |
83,250 |
138,750 |
|
5 |
97,410 |
162,350 |
|
>5 |
||
|
BENDEKA (bendamustine) |
|
Clozapine |
|
Cyclosporine capsules modified |
|
Cyclosporine oral solution modified |
|
GABITRIL (tigabine hydrochloride)
tablets |
|
GALZIN (zinc acetate) capsules |
|
GRANIX (tbo-filgrastim) injection |
|
HERZUMA (trastuzumab-pkrb) injection |
|
NUVIGIL (armodafinil) tablets [C-IV] |
|
ProAir RespiClick (albuterol sulfate)
inhalation aerosol |
|
ProAir HFA (albuterol sulfate)
inhalation aerosol |
|
Proglycem (diazoxide) oral suspension |
|
QNASL (beclomethasone) nasal aerosol |
|
QVAR RediHaler (beclomethasone
dipropionate HFA) inhalation aerosol |
|
SYNRIBO (omacetaxine) for injection |
|
TREANDA (bedamustine) for injection |
|
TRISENOX (arsenice trioxide) injection |
|
TRUXIMA (rituximab-abbs) injection |
Contact
info-Phone: 877-237-4881 Fax: 877-438-4404
Tolmar Total solutions
|
Eligibility |
||
|
US resident |
< 500% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<500% FPL) |
|
1 |
67,950 |
|
2 |
91,550 |
|
3 |
115,150 |
|
4 |
138,750 |
|
>5 |
Click for FPL for household larger than 5 or add 23,600 per each
additional person |
|
Medication eligible for assistance |
|
Eligard
(leuprolide) |
Contact
info-Phone: 1-844-TOLMAR1 Fax: 1-844-TOLMAR2
Veltassa Konnect
|
Eligibility |
||
|
US resident |
< 500% FPL |
Uninsured/Medicare |
|
Household size |
Annual household income ($) threshold (<500% FPL) |
|
1 |
67,950 |
|
2 |
91,550 |
|
3 |
115,150 |
|
4 |
138,750 |
|
>5 |
Click for FPL for household larger than 5 or add 23,600 per each
additional person |
|
Medication eligible for assistance |
|
Veltassa
(patiromer) |
Contact
info-Phone: 1-8888-623-7092 Fax: 1-888-623-7092
PAPs
by Disease State/Condition
|
Medications
available for assistance |
|
Medication class |
Medication name |
|
Anticoagulant |
|
|
Antiplatelet |
|
|
Clotting factor |
|
|
Thrombolytic |
|
|
Medications
available for assistance |
Disease state |
|
Rheumatoid arthritis |
|
|
Sickle cell |
|
|
Plaque psoriasis,
Crohn’s, Ulcerative colitis, Rheumatoid arthritis |
|
|
Lupus nephritis |
|
|
Crohn’s, Ulcerative colitis |
|
|
Atopic dermatitis |
|
|
Plaque psoriasis, Psoriatic arthritis, Ankylosing
spondylitis |
|
|
Pancreatic insufficiency |
|
|
Transplant, Rheumatoid arthritis, Psoriasis |
|
|
Transplant, Rheumatoid arthritis, Psoriasis |
|
|
Nephropathic cystinosis |
|
|
Crohn’s, Ulcerative colitis |
|
|
Wilson's disease, cystinuria |
|
|
Crohn’s, Ulcerative colitis |
|
|
Plaque psoriasis, Psoriatic arthritis, Ankylosing
spondylitis |
|
|
Neuromyelitis optica spectrum disorder |
|
|
Idiopathic pulmonary fibrosis |
|
|
Spinal muscular atrophy |
|
|
Multiple sclerosis, relapsing |
|
|
Transplant, Rheumatoid arthritis, Psoriasis |
|
|
Growth hormone deficiency or failure (pediatrics) |
|
|
Multiple sclerosis, relapsing |
|
|
Multiple sclerosis, relapsing |
|
|
Hemophilia A, prophylaxis |
|
|
Growth hormone deficiency or failure (pediatrics) |
|
|
Plaque psoriasis,
Crohn’s, Ulcerative colitis, Rheumatoid arthritis |
|
|
Adult onset Still's disease, Periodic fever syndromes |
|
|
Plaque psoriasis,
Crohn’s, Ulcerative colitis, Rheumatoid arthritis |
|
|
Crohn’s, Ulcerative colitis |
|
|
Chronic hepatitis C |
|
|
Mayzent® (Siponimod) |
Multiple sclerosis |
|
Peripheral stem cell mobilization |
|
|
Immune thrombocytopenia |
|
|
Kidney transplant (de novo use) |
|
|
Multiple sclerosis, relapsing or primary progressive |
|
|
Idiopathic pulmonary fibrosis |
|
|
Rheumatoid arthritis |
|
|
Growth hormone deficiency or failure (pediatrics) |
|
|
Graft vs host disease, Psoriatic arthritis, Rheumatoid
arthritis |
|
|
Psoriasis, Psoriatic arthritis, Bechet disease |
|
|
Chronic hepatitis B |
|
|
Crohn’s, Ulcerative colitis |
|
|
Multiple sclerosis, relapsing |
|
|
Immune thrombocytopenia |
|
|
Renal transplant, lymphangioleiomyomatosis |
|
|
Anemia due to myelodysplastic syndromes |
|
|
Plaque psoriasis,
Crohn’s, Ulcerative colitis, Rheumatoid arthritis |
|
|
Psoriatic arthritis, Atopic dermatitis, Ulcerative colitis, Rheumatoid arthritis |
|
|
Rheumatoid arthritis |
|
|
Crohn’s, Ulcerative colitis |
|
|
Systemic lupus erythematosus, moderate to severe |
|
|
Crohn’s, Ulcerative colitis |
|
|
Psoriatic arthritis, Ankylosing spondylitis, Ulcerative colitis, Rheumatoid arthritis |
|
|
Plaque psoriasis, Psoriatic arthritis |
|
|
Acromegaly |
|
|
Crohn’s, Plaque psoriasis, Psoriatic arthritis,
Ulcerative colitis |
|
|
Ankylosing spondylitis, Plaque psoriasis, Psoriatic
arthritis |
|
|
Plaque psoriasis, Psoriatic arthritis |
|
|
Rheumatoid arthritis |
|
|
Pancreatic insufficiency |
|
|
Amyloid cardiomyopathy |
|
|
Ankylosing spondylitis, Plaque psoriasis, Psoriatic
arthritis, Rheumatoid arthritis, Ulcerative colitis |
|
|
Hemophilia A |
|
|
Pancreatic insufficiency |
|
|
Multiple sclerosis, relapsing |
|
|
Medications available for assistance |
|
Medication class |
Medication name |
|
DPP4 inhibitor |
|
|
GLP-1 |
|
|
GLP-1 insulin combo |
Soliqua® 100/33 (Insulin Glargine &
Lixisenatide) Injection 100 Units/Ml And 33 Mcg/mL |
|
Insulin |
|
|
Rapid acting |
|
|
Short acting |
|
|
Intermediate acting |
|
|
Long acting |
|
|
Toujeo® (insulin glargine injection) 300
Units/mL (1.5 mL or 3.0 mL pens) |
|
|
Mixed
insulin |
|
|
Rapid/Intermediate |
Humalog® Mix50/50™ (Insulin Lispro
Protamine And Insulin Lispro Injectable Suspension) |
|
Humalog® Mix75/25™ (Insulin Lispro
Protamine And Insulin Lispro Injectable Suspension) |
|
|
Novlog Mix 70/30 (Insulin
Aspart Protamine And Insulin Aspart) Flexpen |
|
|
Regular/Intermediate |
Humulin® 70/30 (Human Insulin Isophane
Suspension And Human Insulin Injection) |
|
SGLT-2 inhibitor |
|
|
Combination oral |
|
|
SGLT2/metformin |
|
|
DPP4/metformin |
|
|
Janumet® Xr (Sitagliptin And
Metformin Hci Extended-Release) Tablets |
|
|
DPP4/SGLT2 |
|
|
DPP4/metformin/SGLT2 |
|
|
DPP4/TZD |
|
|
Other |
|
|
Hypoglycemia management |
|
|
|
|
|
|
|
|
Medication class |
Medication name |
|
ICS+ |
|
|
Qvar Redihaler (Beclomethasone Dipropionate
Hfa) Inhalation Aerosol |
|
|
ICS (nasal) |
|
|
LAMA/LABA |
|
|
LABA/ICS |
|
|
LABA* |
|
|
LAMA |
|
|
LAMA/LABA/ICS |
|
|
SABA/SAMA |
|
|
SABA |
|
|
SAMA |
|
|
Other |
|
|
+ Not to be prescribed
as monotherapy in COPD * Not to be prescribed as monotherapy in Asthma ICS=inhaled corticosteroid, LABA=long
acting beta agonist, LAMA=long acting muscarinic antagonist, SABA=short
acting beta agonist, SAMA=short acting muscarinic antagonist |
|
|
Medications
available for assistance |
|
Fetzima (Levomilnacipran) Extended Release
Capsules And Titration Pack |
|
Lamictal (Lamotrigine Chewable Or Orally Disintegrating Tablets) |
Produced by:
Transitions of care
pharmacist liaison
Last
revised: 9/12/2022
Copyright 6/3/2022